Aranesp with ckd

kathleeng

Networker
Messages
55
Location
Fresno, CA
Best answers
0
Billing for Aranesp J0881 for anemia of ckd. Is anyone familiar with what stage of ckd is required to be reimbursable? I have found one LCD that states it must be anything higher than ckd3 but another LCD states any stage, even unspecified N18.9; of course, I understand every health plan has it's own criteria but I'm just trying to find out what the general rule is.
 

rachaelwilleford

Networker
Messages
51
Location
Carencro, LA
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0
I was told during a Novitas webinar the following regarding coverage:
A procedure can have other policies or guidelines besides an LCD (not an all inclusive list of places to check):
1)MAC website
*Look for a Billing & Coding Article on the MAC Website by doing a standard search
*Check the status indicator on the Fee Schedule (JH)(JL)

2) CMS website:
*Review the NCDs
*Search the CMS Manual for instruction
*Review the National Correct Coding Initiative (NCCI) and Medially Unlikely Edits (MUE) edits on CMS website
*Search for Medicare Learning Network (MLN) articles

3) If no results, Reasonable and Necessary Guidelines (JH) (JL) still apply in accordance with The Social Security Act 1862
(a)(1)(A) :
*Services are safe and effective
*Services are not experimental or investigational
*Services are appropriate, including the duration and frequency
*Providers should report the most appropriate ICD-10 code that adequately describes the patients medical condition at the
time of the service and documented clearly: Ensure the medical necessity is supported in the documentation
*All services furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of illness or
injury or to improve the functioning of a malformed body member
 

trarut

Expert
Messages
309
Location
Columbus, OH
Best answers
0
Billing for Aranesp J0881 for anemia of ckd. Is anyone familiar with what stage of ckd is required to be reimbursable? I have found one LCD that states it must be anything higher than ckd3 but another LCD states any stage, even unspecified N18.9; of course, I understand every health plan has it's own criteria but I'm just trying to find out what the general rule is.
It's my understanding that patients with Stage 1 or 2 CKD do not have GFR or creatinine clearance levels to qualify for epoetin therapy. Did you check the Aranesp package insert to see if it has the information you are looking for?
 
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